New Hampshire Orthopaedic Center Physicians Named as ‘Top Docs’ for 2017

Posted on March 17, 2017.

Each year, roughly 3,000 physicians licensed to practice in New Hampshire are asked to nominate … Read More

Official Orthopaedic Providers for the Manchester Monarchs

Posted on November 28, 2016.

New Hampshire Orthopaedic Center is proud to extend our partnership with the Manchester Monarchs for … Read More

Youth Sports Safety Week 2016

Posted on November 1, 2016.

Youth Sports Safety Week is 2 weeks away! All services to athletes are FREE! Call … Read More

New Hampshire Orthopaedic Center

Do Knee Injuries Cause Arthritis?

Posted on February 25, 2017.

by: Kathleen A. Hogan, MD

Watching football on Sunday afternoon, your favorite player twists their knee and lays on the ground. Have they torn a ligament or meniscus? Or will they be back playing later in the game? What impact do knee injuries have on the eventual development of osteoarthritis?

Many Factors Influence Arthritis Development


The development of arthritis is multifactorial. Body weight, leg alignment, and genetic factors all influence the eventual breakdown of joint cartilage. Injuries certainly play a role as well.

Intra-articular fractures which directly damage the joint surface, are the most extreme examples of an injury which has a known increase in the development of arthritis. Even when the pieces are carefully put back in place and fixed with plates and screws, once broken the joint cartilage will never quite be the same.

Injuries to the Meniscus and Ligaments

What about sports injuries to meniscus and ligaments? The meniscus is a crescent shaped, fibro-cartilage structure that is found on the inner and outer side of the knee joint. It helps to dissipate friction and weight bearing forces arcross the knee joint, protecting the articular cartilage. Before the importance of the meniscius was recognized, the treatment for a torn meniscus was to remove it in its entirety. Unfortunately, arthritis often developed many years later. Forty years after a total meniscectomy as a teenager, patients were 4 times more likely to have developed symptomatic arthritis in that knee compared to the non operated knee.

Meniscus Damage

Today, surgeons try to preserve the meniscus as best possible. In younger patients, meniscus repair is sometimes possible. In older patients, only the torn portion of the meniscus is removed. However, the same forces that damaged the meniscus may have also damaged the cartilage of the knee. In one study, 43% of patients (average age 49) undergoing surgery for a torn meniscus were found to have damage to the articular cartilage of the knee, damage that was graded as severe in half of those cases.

Anterior Cruciate Ligament (ACL) Repair

The anterior cruciate ligament (ACL) functions to keep the tibia balanced under the femur during rotational motions. The forces generated during rupture of the ligament often damage the articular cartilage of the knee. Repair of the ligament helps to prevent instability and it is theorized that this protects cartilage from further injury. The type of surgical repair, concurrent meniscus injuries, and patient activity may all influence the development of later arthritis. One Swedish study found a 10% incidence of post traumatic arthritis of the knee 10 years after injury. Other studies have found a much higher rate of arthritis.

Knee Injuries Influence Development of Arthritis

Knee injuries certainly do influence the development of arthritis. A prospective study of 1321 medical students followed for 22 years found that a knee injury as a young adult increased the incidence of knee arthritis from 6% to 13% at age 65. The risk in high performance athletes is likely higher. A retrospective review of athletes at the NFL Combine who had undergone MRI to evaluate prior injuries found evidence of early arthritis in 11% of those with meniscus repair, 24% with ACL repair, and 27% with partial menisectomy!

Preventing Further Injury

Although techniques of repairing damaged articular cartilage, meniscus, and ligaments are improving, injury prevention is the best way to limit cartilage damage in the knee from sports. If you have had a significant injury to your knee in the past, your risk of developing arthritis in that knee is certainly higher, but not inevitable. Just because X-rays may show arthritis, this does not mean that you will require joint replacement surgery. Minimizing further damage by keeping your legs muscles strong, your joints flexible, and your weight within a normal range are very important if you have had prior knee injuries.

How Does Gaining Weight Affect Your Knees?

Posted on January 17, 2017.

by Kathleen A. Hogan, MD

The holidays are a time when many people eat and drink a bit too much and then resolve to lose that weight in the new year. Unfortunately, once weight is gained, it is often difficult to lose. Many people notice that gaining weight seems to affect their joints, causing knee pain. Does excessive body weight cause knee arthritis or just make the symptoms worse?

Relationship Between Body Weight and Knee Arthritis

Symptomatic knee arthritis affects approximately 13% of women and 10% of men over the age of 60 in the United States. There are many causes of knee arthritis including age, injury, mechanical mal-alignment, and genetic factors. Multiple studies have shown a relationship between body weight and the development of knee arthritis. For example, a person with a body mass index (BMI) of over 30 (obese) has an almost 7 times increases in the incidence of knee arthritis compared to someone with a BMI of less than 25 (normal weight). A BMI increase of 5 points is associated with an over 30% increase in the prevalence of knee arthritis.

Impact of Increased Body Weight

How does this increased weight cause knee arthritis? Elevated body weight increases the mechanical stresses on the knee joint. Every 1 pound of weight gained increases the forces on the knee by a factor of 4. Decreased activity many lead to decreased muscle strength which also increases joint reactive forces. Gait analysis studies have shown that the compressive and sheer forces on the tibia-femoral joint are much higher in patients with elevated body mass compared to normal weight individuals. In a study of identical twins, every 1 kg weight gain (2.2 lbs) was found to increase the likelihood of X-ray findings of arthritis in the knee and hands by 9-13%. It is also thought that there may be metabolic and inflammatory factors in patients who are overweight which also contribute to cartilage damage, even in non weight bearing joints such as the hand. Inflammatory cytokines such as TNF alpha and interleukin -1 and adipokines such as leptin and adionectin are elevated in patients with obesity. The role of these factors in the development of arthritis is currently being studied.

Benefits of Loosing Weight

Does losing weight help with knee pain even if you have arthritis? Yes, multiple studies show that weight loss does have beneficial effects, even in patients with x-ray findings of arthritis. Women in the Framingham Knee Osteoarthritis Study who lost weight (BMI decrease of 2 points) significantly decreased their probability of developing knee arthritis. Other studies have shown that when obese patients were able to lose 10% of their body weight, there was a significant improvement in knee pain, physical function, and decreased knee compressive forces with walking. MRIs can also show improvement in knee cartilage with weight loss. The American Academy of Orthopedic Surgeons (AAOS) recommends weight loss through diet and exercise for patients with knee arthritis and a BMI of > 25. Multiple studies have shown the benefit of low impact aerobic exercise and strengthening to improve the symptoms of knee arthritis.

Recommendations for the New Year

Gaining weight can certainly increase the likelihood of developing joint pain and arthritis. If you find yourself putting on a few pounds over the holiday, make sure you stick to your New Years resolution to shed those pounds, as they tend to accumulate if not gotten rid of quickly! While knee arthritis can not always be prevented, low impact exercise, strength training, and maintaining a healthy body weight can help decrease your chance of needing joint replacement in the future.

How Does Body Weight Affect Knee Arthritis?

Posted on December 23, 2016.

by Kathleen A. Hogan, MD

The holidays are a time when many people eat and drink a bit too much and then resolve to lose that weight in the new year. Unfortunately, once weight is gained, it is often difficult to lose. Many people notice that gaining weight seems to affect their joints, causing knee pain. Does excessive body weight cause knee arthritis or just make the symptoms worse?

Relationship Between Body Weight and Knee Arthritis

Symptomatic knee arthritis affects approximately 13% of women and 10% of men over the age of 60 in the United States. There are many causes of knee arthritis including age, injury, mechanical mal-alignment, and genetic factors. Multiple studies have shown a relationship between body weight and the development of knee arthritis. For example, a person with a body mass index (BMI) of over 30 (obese) has an almost 7 times increases in the incidence of knee arthritis compared to someone with a BMI of less than 25 (normal weight). A BMI increase of 5 points is associated with an over 30% increase in the prevalence of knee arthritis.

Impact of Increased Body Weight

How does this increased weight cause knee arthritis? Elevated body weight increases the mechanical stresses on the knee joint. Every 1 pound of weight gained increases the forces on the knee by a factor of 4. Decreased activity many lead to decreased muscle strength which also increases joint reactive forces. Gait analysis studies have shown that the compressive and sheer forces on the tibia-femoral joint are much higher in patients with elevated body mass compared to normal weight individuals. In a study of identical twins, every 1 kg weight gain (2.2 lbs) was found to increase the likelihood of X-ray findings of arthritis in the knee and hands by 9-13%. It is also thought that there may be metabolic and inflammatory factors in patients who are overweight which also contribute to cartilage damage, even in non weight bearing joints such as the hand. Inflammatory cytokines such as TNF alpha and interleukin -1 and adipokines such as leptin and adionectin are elevated in patients with obesity. The role of these factors in the development of arthritis is currently being studied.

Benefits of Losing Weight

Does losing weight help with knee pain even if you have arthritis? Yes, multiple studies show that weight loss does have beneficial effects, even in patients with x-ray findings of arthritis. Women in the Framingham Knee Osteoarthritis Study who lost weight (BMI decrease of 2 points) significantly decreased their probability of developing knee arthritis. Other studies have shown that when obese patients were able to lose 10% of their body weight, there was a significant improvement in knee pain, physical function, and decreased knee compressive forces with walking. MRIs can also show improvement in knee cartilage with weight loss. The American Academy of Orthopedic Surgeons (AAOS) recommends weight loss through diet and exercise for patients with knee arthritis and a BMI of > 25. Multiple studies have shown the benefit of low impact aerobic exercise and strengthening to improve the symptoms of knee arthritis.

Recommendations for the New Year

Gaining weight can certainly increase the likelihood of developing joint pain and arthritis. If you find yourself putting on a few pounds over the holiday, make sure you stick to your New Years resolution to shed those pounds, as they tend to accumulate if not gotten rid of quickly! While knee arthritis can not always be prevented, low impact exercise, strength training, and maintaining a healthy body weight can help decrease your chance of needing joint replacement in the future.

Does Wearing High Heels Damage Your Knees?

Posted on November 27, 2016.

by: Kathleen A. Hogan, MD

It is hard not to notice when a women walks down the street or through the hospital in 3 inch stiletto heels. It is estimated that over 40% of women wear high heals daily. Most of these shoes are not comfortable after several hours of wear and the potential negative effects of tight fitting shoes on the feet are well established. Wearing heels can also cause the muscles in the back of the leg to tighten, making it difficult for some women to place their heel on the ground when walking in flats.

But does wearing high heels do damage to other joints? Women have a higher rate of osteoarthritis of the knee compared to men. It is not well established if this increased incidence is a result of differences in hormone levels, obesity rates, or anatomy. Could wearing high heels increase the risk of arthritis?

Many women who have knee problems will stop wearing high heels because they hurt. Also, many women find as they get older they no longer wish to wear shoes that are not comfortable and that may increase their risk of falls. However, this does not prove that high heels cause arthritis.

Biomechanics of Knee Motion While Wearing High Heels

There are only a few studies that have looked at the biomechanics of knee motion while wearing high heels. In one study, 14 women were asked to walk in sneakers, 1.5 inch heals, and 3 inch heals. As heel height increased, walking speed decreased. Knee flexion increased at heal strike and mid stance. Knee adduction also increased as heel height increased, indicating possibly more reactive forces placed on the knee joint. Other studies have shown increased knee torque and patellofemoral joint reactive forces when high heels are worn.

These studies do not mean that wearing high heels causes arthritis. However, certainly wearing heals will alter gait and may lead to knee pain. Other than wearing sneakers, what can be done to minimize the effects of this increased stress on the knee?

How to Minimize the Effects of Increased Stress on the Knee

Balance is a crucial part of gait. Can you stand on one leg without loosing your balance? Can you do that in heels? When you walk, you spend a portion of your stride with one leg off the ground. If your balance is poor, you will put more stress on the muscles of your hip and knee as you struggle to compensate. Improving balance and strengthening gluteal muscles will take stress off the knees and hips as you walk in heels. Squats and lunges help to improve your dynamic stability.

Standing in heels changes the center of gravity, requiring more effort by the muscles of the low back to keep you standing straight. Core exercises to strengthen the abdominal and low back muscles are essential to maintaining good posture while wearing heels.

Stretching is also important Yixing Teapots. The calf and foot muscles tighten and contract to maintain that position. If these muscles are not routinely stretched and lengthened, they may become permanently contracted and stiff.

Conclusion

Although wearing high heels has been shown to place additional stresses on the feet and knees, there is no definitive proof that these added stresses result in arthritis. The added stress on the knees of being overweight is a much more important factor in the development of knee arthritis than shoe wear. Flexibility and strength are key to maintaining good posture while walking in heels. Limit the height of your heels to shoes you can balance in while standing on one leg. Find shoes that are more comfortable, with a wider toe box and thicker heel if necessary. And never let anyone talk you out of wearing shoes that you love.

Knee Replacements in the Congo – Part 4

Posted on October 13, 2016.

by: Kathleen A. Hogan, MD

I am part of a group of female orthopedic surgeons (WOGO) who travel to third world countries to improve the lives of people by improving mobility through joint replacement. In July, we traveled to the Democratic Republic of Congo (DRC) as guests of the Dikembe Mutombo Foundation to perform knee replacement surgeries. This was an incredibly challenging trip and rewarding trip.

Exhausted, Elated and Disappointed

In four days of surgery, we replaced 42 knees. The last few days in DRC were bittersweet. We were exhausted from operating late almost every night. We were elated to have accomplished so much, but disappointed we did not get all the surgeries done. But time had run out. Another visiting surgeon had come to operate and we also didn’t want to leave the country the day after patients had just had surgery.

Visits to An Orphanage and Maternity Hospital

We had 2 days left. We packed cargo. We spent time with our patients. We traveled to an orphanage on the outskirts of Kinsasha. WOGO partners with Soles-4-Souls, a non profit organization which delivers shoes to people in third world countries. We visited with the children in the orphanage, and sat in the dirt to fit them with shoes. It was organized chaos with lots of smiling happy children. We also visited a maternity hospital. Many of us packed extra luggage full of baby onesies and blankets, and every new mother there went home went home with a care package of new baby clothes.

Lola ya Bonobo Sanctuary

We did do a few “fun” activities while we were there. We spent an afternoon visiting the Lola ya Bonobo Sanctuary. Bonobos are members of the great ape family – as closely related to humans as are chimpanzees. Unlike chimps, they do not fight each other for food or dominance And the female bonobos are in charge. Bonobos live only in the Congo and are endangered. Their habitat has been devastated by civil war and monkeys are sold as gifts and eaten as food. This sanctuary was founded by a Congolese women who has dedicated her life to raising and protecting orphan bonobos.

Congolese Symphony

We also saw the Congolese Symphony perform. Yes, in the midst of this poverty there is a symphony. It is the only symphony in Central Africa. Many of the musicians taught themselves to play on homemade instruments. They are unpaid and have other jobs during the day We saw them perform in an old school gymnasium and they were amazing.

Kind, Friendly People Enduring Terrible Tragedy

If you read the stories of civil wars and child soldiers, and rape and corruption, you know that the people here have endured terrible tragedies. The poverty is unbelievable. Garbage litters city streets. Police officers and civil servants go without pay. Presidential elections are cancelled. Doctors work more than one job to pay the bills. I saw men with machine guns sitting on top of trucks. Yet the people we met were kind, friendly, and wonderful. They dress with a keen sense of fashion and color. People were genuinely happy we were there. The team of nurses and doctors at the hospital stayed late to help us out and often slept there. The police officers with machine guns who traveled with us cared about our safety and became part of our team too, even joining us in giving out shoes at the orphanage.

Our Last Day – Looking Forward to Returning to the Congolese People

The last day at the hospital, we brought all the patients outside to take a group photo. All of the patients started clapping their hands and singing “God is so Good.” I cried. I think everyone did. It was an emotional, exhausting, amazing trip. The DRC is so much more than a failed state. I understand now why Dikembe Mutombo is so dedicated to helping the people from his homeland. His hospital does so many great things – vaccinations, cervical cancer screening, hearing aid distribution, cataract surgery, and now joint replacements. WOGO hopes to raise enough money to go back to DRC next year and continue helping the wonderful Congolese people. Learn more about our trip at Women Orthopaedist Global Outreach and the Dikembe Mutombo Foundation.